| QNo. | Questions and Instructions | Response | Code |
| 1 | Is the child well today? | Yes No | 1 2 |
| 2 | Does the child have febrile illness? | Yes No | 1 2 |
| 3 | Does the child have cough? | Yes No | 1 2 |
| 4 | Does the child have pain? | Yes a) chest pain b) abdominal pain c) back pain d) Joint pain e) headache f) other-(specify) No | 1
2 |
| 5 | Does the child have joint swelling or toes or fingers swelling? or swelling anywhere | No Yes If yes (specify) | 1 2
|
| 6 | Does the child have yellowish discoloration of the eyes? | No Yes | 1 2 |
| 7 | Does the child have hx of nasal bleeding? | Yes No | 1 2 |
| 8 | Does the child have hx of leg ulcers? | Yes No | 1 2 |